View Information Collection Request (ICR) Package

View ICR - Agency Submission

Comment Period Closed - Comments are accepted for the first 30 days of OIRA's review. See FAQ page for more information.

OMB Control No: 0915-0285	ICR Reference No: 202603-0915-004
Status: Received in OIRA	Previous ICR Reference No: 202505-0915-002
Agency/Subagency: HHS/HSA	Agency Tracking No: 21063
Title: The Health Center Program Application Forms
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 04/23/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	05/31/2026
Responses	30,350	39,279
Time Burden (Hours)	32,789	47,058
Cost Burden (Dollars)	0	0

ICR Summary of Burden

	Total Request	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	30,350	39,279	-8,929
Annual Time Burden (Hours)	32,789	47,058	-14,269
Annual Cost Burden (Dollars)	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Changing Forms

Short Statement: The OMB Inventory currently contains 46,529 burden hours for this activity. This request is for 32,785.55 total burden hours, for a decrease of 14,269 hours. The decrease in hours is due to a decline in the number of applicants, from 39,279 to 30,350, that will use these forms as well as the reduction in the number of forms.

Annual Cost to Federal Government: $293,939

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

Agency Contact: Laura Cooper 301 443-2126 lcooper@hrsa.gov

Something went wrong when downloading this file. If you have any questions, please send an email to risc@gsa.gov.